Fields with an asterisk "*" are required.

Today's Date

Name: (First, Middle, Last) *
(if victim is deceased, list name here)

Victim's DOB * (MM/DD/YYYY) / /

Name of person filling out this form
(if different from the victim)

What is your date of birth and relationship to the victim:

Your DOB * (MM/DD/YYYY) / /

Your Relationship

Contact information

Complete Mailing address (including City, State, ZIP)*
Address 1

Address 2

City State Zip

Main Contact Phone: * ( ) -

Work Phone: ( ) -

Cell Phone:( ) -


What is the nature of the crime? (Select all that apply)*

Assault Sexual Offense Property Domestic Violence


What was the approximate date of the crime?

(MM/DD/YYY) * / /

Defendant's/suspect's name and date of birth:


Please give a brief description of the crime:*

Was the crime reported to law enforcement?

If yes, what is the name of the law enforcement agency?:

Did law enforcement provide any notification/information about the Office of Victims’ Rights to you? *

How did you learn about the Office of Victim's Rights?:*

Do you have any concerns about any criminal justice agencies?

If yes, which one?

Have you addressed this matter with the agency?

Have you sought help from any other office, attorney, or victims' services agency?

Crime Victims' Rights *

Please select all that apply if you as a crime victim believe your rights have been violated, believe your rights will be violated, or have any concerns your victim rights may be violated.

To be treated with dignity, fairness, and respect

To a timely conclusion of the case

To the protection of my privacy right regarding personal information (medical counseling, mental health or substance abuse treatment, or contents of computers or cellphones)

To speak with prosecutor about proposed plea offer before acceptance in DV or felony cases

To have portions of the pre-sentencing report, if prepared, in felony cases

To be present and address the court at sentencing

To the notice of trial and right to be present at trial

To a hearing for return of my property seized by law enforcement

To receive restitution from the defendant

Other (please provide description)


The Office of Victims’ Rights (OVR) will maintain confidentiality with respect to all matters, including your identity, and that of witnesses coming before the OVR except insofar as, in the judgment of the OVR, disclosures are authorized by law and/or as may be necessary in order to enable this office to carry out its duties and to support its recommendations. This means that in the course of processing this complaint – request for assistance form and/or providing services in this case, it may become necessary for the OVR to use your name and/or other information about your case that you have provided, or which was acquired by the OVR in the discharge of our official duties, as a result of submitting this complaint – request for assistance form to us. By signing below you are agreeing that, in the judgment of the OVR, we may use your name and discuss and/or disclose information and/or documents and/or the facts of this case with others, including but not limited to others within the executive, legislative, or judicial branches of government, private or public agencies or offices, in open court and/or to the general public, or others, in the formulation of our findings and recommendations and in the discharge of our duties. The services of the Office of Victims’ Rights are free.


Social Security, Operator's License Or Other Unique Identifier:* (This is an electronic signature that will be used to verify your identity when we contact you)